OLD - Interactive Support & Guidance Application

INTERACTIVE SUPPORT & GUIDANCE APPLICATION

To apply for a month of free therapy from our friends at BetterHelp, please complete this form.

If you would like for your friend or family member to receive therapy, please send them this form or complete it with them.

Required Info

First Name *

Last Name *

Contact Info

Please note: your email address will be used to invite you to create your BetterHelp account.

Email Address *

Double-confirm your email please *

Would you be willing to tell us about your experience after your month is up?

Please note: this DOES NOT affect your chances of receiving therapy, it's just so we don't bug anyone who doesn't want us to bug them. *

Yes

Optional Info

Please note before completing the next section:

Everything below this point is optional. Completing it just tells us about who's participating, and this information will be anonymized before it's shared.

Whether you complete this section DOES NOT affect whether you will receive therapy.

Have you ever had therapy before?

Yes

For what reasons are you seeking therapy?

Improving Mental Health

Life Advice

Optimizing & planning for the future

Other Other

On a scale of 1-10, how would you rate your happiness?

What do you hope therapy will change for you?

Report abuse